Diagnosis and management of life-threatening cardiac malformations in the newborn

Outcomes of Neonatal Cardiac Surgery: A European Congenital Heart Surgeons Association Study

BACKGROUND

We evaluated outcomes of neonatal cardiac surgery at hospitals affiliated with the European Congenital Heart Surgeons Association (ECHSA).

METHODS

All patients ≤30 days of life undergoing a cardiac surgical procedure during a 10-year period between January 2013 and December 2022 were selected from the ECHSA Congenital Database. Reoperations during the same hospitalization, percutaneous procedures, and noncardiac surgical procedures were excluded. We identified 12 benchmark operations. Primary outcomes were 30-day mortality and in-hospital mortality. Multivariable logistic regression analysis was performed to determine independent factors associated with higher mortality. Mortality between the first 5 years and second 5 years was also compared.

RESULTS

The overall number of neonatal operations from 2013 to 2022 was 30,931, and 22,763 patients met the inclusion criteria of the study. The 4 most common procedures were arterial switch operation (3520 of 22,763 [15.5%]), aortic coarctation repair (3204 of 22,763 [14.1%]), shunt procedure (2351 of 22,763 [10.3%]), and Norwood operation (2115 of 22,763 [9.23%]). The 30-day mortality rate was as follows: overall population, 5.9% (1342 of 22,763); arterial switch, 3.13% (110 of 3520); Norwood operation, 16.0% (339 of 2115); and hybrid operation, 15.4% (94 of 609). In-hospital mortality rate was as follows: overall population, 9.1% (2074 of 22,763); arterial switch, 4.12% (145 of 3520); Norwood operation, 24.7% (523 of 2115); and hybrid operation, 30.5% (186 of 609). Multivariable analysis revealed that major factors impacting mortality were high-risk procedures (adjusted odds ratio, 2.74; 95% CI, 2.33-3.23; P < .001), and the need for extracorporeal membrane oxygenation (11.8; 95% CI, 9.9-14; P < .001).

CONCLUSIONS

Neonatal cardiac surgery continues to pose a significant challenge, with notable mortality, particularly for neonates with functionally univentricular physiology. These data can serve as important benchmarks across Europe and offer insights regarding opportunities for improvement.

A multicenter study on two-stage transfer learning model for duct-dependent CHDs screening in fetal echocardiography

Duct-dependent congenital heart diseases (CHDs) are a serious form of CHD with a low detection rate, especially in underdeveloped countries and areas. Although existing studies have developed models for fetal heart structure identification, there is a lack of comprehensive evaluation of the long axis of the aorta. In this study, a total of 6698 images and 48 videos are collected to develop and test a two-stage deep transfer learning model named DDCHD-DenseNet for screening critical duct-dependent CHDs. The model achieves a sensitivity of 0.973, 0.843, 0.769, and 0.759, and a specificity of 0.985, 0.967, 0.956, and 0.759, respectively, on the four multicenter test sets. It is expected to be employed as a potential automatic screening tool for hierarchical care and computer-aided diagnosis. Our two-stage strategy effectively improves the robustness of the model and can be extended to screen for other fetal heart development defects.

Paradoxical Continuous Left-to-Right Ductal Shunt during Circulatory Collapse due to Ductal Closure in an Infant with Duct-Dependent Systemic Circulation

Duct-dependent systemic circulation is accompanied by a right-to-left ductal shunt, at least during systole. Although observations of paradoxical continuous left-to-right shunts in duct-dependent systemic circulation have been reported, the mechanism remains unclear. We report a continuous left-to-right ductal shunt throughout the cardiac cycle during the initial recovery phase from circulatory collapse and right ventricular (RV) dysfunction due to ductal closure in an infant with hypoplastic left heart and severe aortic coarctation. Further recovery improved his RV function and changed the ductal flow from continuous left-to-right to bidirectional, which is usually seen in duct-dependent systemic circulation. Marked RV dysfunction may contribute to the continuous left-to-right ductal shunt. A continuous left-to-right ductal shunt should not be used to rule out duct-dependent systemic circulation.

Efficacy and safety of Mydriatic Microdrops for Retinopathy Of Prematurity Screening (MyMiROPS): study protocol for a non-inferiority crossover randomized controlled trial

BACKGROUND

Retinopathy of prematurity (ROP) eye examination screening presupposes adequate mydriasis for an informative fundoscopy of preterm infants at risk, on a weekly basis. Systemic absorption of the instilled mydriatic regimens has been associated with various adverse events in this fragile population. This report aims to present the fully developed protocol of a full-scale trial for testing the hypothesis that the reduced mydriatic drop volume achieves adequate mydriasis while minimizing systemic adverse events.

METHODS

A non-inferiority crossover randomized controlled trial will be performed to study the efficacy and safety of combined phenylephrine 1.67% and tropicamide 0.33% microdrops compared with standard drops in a total of 93 preterm infants requiring ROP screening. Primary outcome will be the pupil diameter at 45 (T45) min after instillation. Pupil diameter at T90 and T120 will constitute secondary efficacy endpoints. Mixed-effects linear regression models will be developed, and the 95% confidence interval approach will be used for assessing non-inferiority. Whole blood samples will be analyzed using hydrophilic liquid chromatography-tandem mass spectrometry method (HILIC-MS/MS), for gathering pharmacokinetic (PK) data on the instilled phenylephrine, at nine specific time points within 3 h from mydriasis. Pooled PK data will be used due to ethical restrictions on having a full PK profile per infant. Heart rate, oxygen saturation, blood pressure measurements, and 48-h adverse events will also be recorded.

DISCUSSION

This protocol is designed for a study powered to assess non-inferiority of microdrops compared with standard dilating drops. If our hypothesis is confirmed, microdrops may become a useful tool in ROP screening.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05043077 . Registered on 2 September 2021.

Improving diagnostic accuracy in neonates with left heart obstruction in a transport setting

AIM

Differentiating left heart obstruction (LHO) from other severe illness in the neonatal period is challenging, and important for guiding clinical management. The aim of this study was to identify factors distinguishing LHO from non-LHO in neonates.

METHODS

A retrospective, cohort study of neonates referred to the Newborn and Paediatric Emergency Transport Service, New South Wales, with suspected LHO during the epoch 1996-2016.

RESULTS

A total of 273 neonates were included; 240 with confirmed LHO. Administration of prostaglandin E₁ to infants with a structurally normal heart was not associated with impaired acid-base or oxygenation status. Pre-transport diagnostic accuracy of LHO was 74.4%; sensitivity 84.5%, positive predictive value 86.0%. On multivariable logistic regression, hepatomegaly (odds ratio 2.54; 95% confidence interval 1.05-6.16) was associated with confirmed LHO.

CONCLUSIONS

A low threshold for prostaglandin E₁ infusion should be maintained in infants with suspected LHO. Hepatomegaly is associated with a diagnosis of LHO and may be more useful than other parameters in predicting the condition.

Aortic Coarctation: A Comprehensive Analysis of Shape, Size, and Contractility of the Fetal Heart

BACKGROUND

An integrated assessment of the size and shape of the 4-chamber view (4-CV) and right and left ventricles (RV and LV) as well as the function of the RV and LV in fetuses with coarctation of the aorta (CoA) has not yet been conducted.

OBJECTIVES

We evaluated the size and shape of the 4-CV, RV, and LV, and function of the RV and LV, to identify a profile for fetuses with CoA when compared to a control population.

METHODS

50 CoA fetuses were compared to 200 controls. This was a retrospective case series comparing the 4-CV of CoA fetuses and controls. The 4-CV end-diastolic area, length, width, and sphericity index were measured to determine the configuration of the 4-CV. Speckle-tracking analysis was used to compute the RV and LV end-diastolic area, length, 24-segment sphericity index, 24-segment transverse width, and the following functional parameters: (1) fractional area change; (2) global, lateral, and septal strain; (3) basal-apical, lateral, and septal annular displacement and fractional shortening; and (4) 24-segment transverse width fractional shortening. Using 5 and 95% reference intervals, the CoA fetal measurements were classified; from these, the odds ratio was computed between the fetuses with CoA and the controls. p < 0.05 was considered significant.

RESULTS

In fetuses with CoA, the 4-CV was spherical in shape, increased in area and width, and decreased in length. Abnormal CoA sphericity indices reflected a flatter LV and a more spherical RV. The LV area, length, and width, and RV length were decreased. The transverse width of the RV was increased. RV and LV global, longitudinal, and transverse contractility were depressed.

CONCLUSIONS

The results demonstrate previously unappreciated differences in the shape, size, and function of the heart in fetuses with CoA. These differences may assist examiners in identifying fetuses with CoA.

Echocardiographic Evaluation in Neonates with Heart Murmurs

Auscultation of the heart is one of the most important tools of physical examination in neonates, which is very helpful in the diagnosis or rejection of congenital heart diseases (CHDs). The aim of this study is to investigate the causes of heart murmur in neonates hospitalized in neonatal unit in Imam Reza Hospital, Kermanshah, Iran. This cross-sectional study was conducted within the period of 18 months on neonates hospitalized in neonatal unit whose heart murmur, diagnosed through examination, and echocardiography was conducted to investigate the existence of CHD. In 62.1% of the cases, murmuring was auscultated within the first week after birth. Among 172 neonates with heart murmur, 25 subjects (14.5%) had normal echocardiogram, and others had abnormal echocardiogram in which ventricular septal defect (31.4%) was the most common CHD. Patent ductus arteriosus (23.3%) was the second common CHD found. Other defects were atrial septal defect, persistent foramen ovale, pulmonary stenosis, and tricuspid regurgitation. Among the neonates with CHD, 55 subjects were females and 92 cases were males. There was CHD history in previous siblings in 10 cases. In 73 neonates with CHD, the mother had not taken folic acid in the first trimester of pregnancy. A total of 14.5% of the hospitalized neonates suffered from innocent murmur, and the rest with heart murmur had abnormal echocardiography and suffered from CHD (85.5%). Heart murmur in neonates could be a symptom of CHD, and timely echocardiography is very important in diagnosing the type of disease.

The value of peripheral perfusion index measurements for early detection of critical cardiac defects

BACKGROUND

Approximately 25% of congenital heart diseases (CHD) are estimated to be critical and require an intervention. In this study, we aimed to investigate the additional value of peripheral perfusion index (PPI) measurements to pulse oximetry screening for critical CHD (CCHD).

METHODS

Infants born at Ege University Hospital between May 2013 and September 2015 were prospectively included in the study. In addition to physical examination, pre- and postductal oxygen saturations and PPI values were measured with a new generation pulse oximeter before discharge from the hospital.

RESULTS

A total of 3175 newborns (33 with an antenatal diagnosis of CCHD) were included in the study. With the combination of physical examination, pulse oximetry screening and peripheral perfusion index (PPI) measurements, all newborns with CCHD were detected in our study including three infants without an antenatal diagnosis in whom pulse oximetry screening was negative.

CONCLUSION

PPI measurements may be valuable for early detection of obstructive left heart lesions where pulse oximetry screening has limitations in diagnosis.

Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience

Objective

Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures.

Methods

This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD.

Results

Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures.

Conclusions

Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.

Screening practices and associated anomalies in infants with anorectal malformations: Results from the Midwest Pediatric Surgery Consortium

BACKGROUND

This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM).

METHODS

We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children's hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed.

RESULTS

Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥1 abnormal finding on any screening test varied by type of ARM (p<0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%).

CONCLUSION

Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients.

TYPE OF STUDY

Multi-institutional retrospective cohort study.

LEVEL OF EVIDENCE

III.

Management of late presentation congenital heart disease

In many parts of the world, mostly low- and middle-income countries, timely diagnosis and repair of congenital heart diseases (CHDs) is not feasible for a variety of reasons. In these regions, economic growth has enabled the development of cardiac units that manage patients with CHD presenting later than would be ideal, often after the window for early stabilisation - transposition of the great arteries, coarctation of the aorta - or for lower-risk surgery in infancy - left-to-right shunts or cyanotic conditions. As a result, patients may have suffered organ dysfunction, manifest signs of pulmonary vascular disease, or the sequelae of profound cyanosis and polycythaemia. Late presentation poses unique clinical and ethical challenges in decision making regarding operability or surgical candidacy, surgical strategy, and perioperative intensive care management.

Toward Improving the Fetal Diagnosis of Coarctation of the Aorta

Coarctation of the aorta (CoA) is the most common ductal-dependent lesion missed on neonatal exam screening. Prenatal diagnosis of CoA improves outcomes through early initiation of prostaglandin. Fetal echocardiographic parameters including 2D and Doppler findings have been studied as predictive measures for fetal diagnosis of CoA, but diagnosis rates remain variable. A comprehensive set of predictor variables was applied to fetuses suspected of CoA to analyze which parameters were associated with postnatal CoA. UCSF Fetal Cardiovascular Program databases were queried for fetuses suspected of CoA (2008-2014). Retrospective measurements of aorta/pulmonary artery ratio (AoPA), LV/RV ratio, ascending aorta Z-score (AscAo), isthmus Z-score, isthmus/duct ratio (I/D), posterior "shelf" of descending aorta, and diastolic flow persistence at the isthmus were recorded. ROC analysis identified the parameters most predictive of postnatal CoA. Among 97 fetuses with probable CoA, 62 had complete follow-up. Of these fetuses, 45 (72.5%) had postnatal confirmation of CoA and 17 did not have CoA. The parameters most predictive of postnatal CoA included AscAo, isthmus Z-score, and I/D, with respective AUC of 0.80, 0.89, and 0.90. Diastolic flow persistence was seen more often in fetuses with postnatal CoA, but did not reach statistical significance. Combining 2D and Doppler criteria (AoPA < 0.65 or diastolic flow persistence) improved sensitivity to 87%, but introduced several false positives. Isthmus imaging and AoPA ratio are useful predictors of CoA. Doppler information was most helpful when 2D imaging was equivocal; its addition resulted in high sensitivity in an enriched cohort referred for fetal echocardiography.